Provider Demographics
NPI:1598229148
Name:ELDRIDGE, TANNER EDWARD
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:EDWARD
Last Name:ELDRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3679 RATTLESNAKE RDG
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164-7975
Mailing Address - Country:US
Mailing Address - Phone:606-922-6786
Mailing Address - Fax:
Practice Address - Street 1:521 LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3100
Practice Address - Country:US
Practice Address - Phone:859-622-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer